Basic Information
Provider Information
NPI: 1003296724
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCCORMICK
FirstName: MOLLY
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: LUNSTRUM
OtherFirstName: MOLLY
OtherMiddleName: M
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 777 N RAYMOND ST
Address2:  
City: BOISE
State: ID
PostalCode: 837049251
CountryCode: US
TelephoneNumber: 2085142500
FaxNumber: 2083752217
Practice Location
Address1: 708 E WYTHE CREEK CT STE 103
Address2:  
City: KUNA
State: ID
PostalCode: 836345005
CountryCode: US
TelephoneNumber: 2089225130
FaxNumber: 2083752217
Other Information
ProviderEnumerationDate: 06/08/2015
LastUpdateDate: 11/21/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XO-1008IDY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000XMRO-1478IDN Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
100329672405ID MEDICAID


Home